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• Disclosure for Conflicts of Interest Evaluation

  This form asks you to name any conflicts of interest that may come up in your appeal process.

• Authorization to Request, Use, or Release Member Psychotherapy Notes Form

  This form is used to instruct HMSA to send or receive your psychotherapy notes that we may have to or from an individual or organization.

• HMSA’s Care Access Assistance Program

  HMSA's Care Access Assistance Program makes it easier for HMSA members to see an HMSA participating specialist on another island.

• Attestation Regarding Protected Health Information Potentially Related to Reproductive Health Care

  Attestation regarding a requested use or disclosure of protected health information potentially related to reproductive health care.

• Essential, Optimal, and Metallic Formulary Coverage Determination Request

  Need a prescription drug that’s not on your formulary? Get instructions on how to start the request process with your doctor.

• Dental Appeals

  You can ask us to recheck a decision about your health plan or prescription drug coverage for services or benefits you've received.

• QUEST Integration Formulary Exception Request

  Need a prescription drug that's not on your formulary? Get instructions on how to start the request process with your doctor.

• Request For Insurance Commissioner External Review

  You can ask to have an independent review organization look over your appeal if you think we made a mistake.

• Commercial Member Form to Appeal

  You can ask us to recheck a decision about your health plan or prescription drug coverage for services or benefits you've received.

• HSTA Travel Reimbursement Benefit Request Form

  Find out if you qualify for HSTA travel reimbursement by filling out this form.

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